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Using Common Scents: Questionnaire

Personal Care Products

Are there any personal care products containing fragrances or scents that cause you to have adverse health reactions?
(check all that apply)

1. Perfumes/Colognes:
Yes
No
If yes, please check all applicable symptoms:  
Headaches Burning/itching eyes  Breathing Difficulty  Skin Rash  Nausea Asthma Attack  Coughing  Sinus, Nose, Throat, Mouth, Lung Irritation  Other 
Of the products that bother you, please list the top three brands; form of delivery; and amount used:
Brand 1.   
Form of Delivery:   Aerosol/Pump Spray  Splash/Lotion 
Amount Used:   Pulse Points  All Over 

Brand 2.   
Form of Delivery:   Aerosol/Pump Spray  Splash/Lotion 
Amount Used:   Pulse Points  All Over 

Brand 3.   
Form of Delivery:   Aerosol/Pump Spray  Splash/Lotion 
Amount Used:   Pulse Points  All Over 
 

 

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